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Missy Bryan, OTR/l, CPST Laura Flynn, PT, PCS

Andy Foster, OTR/L, ATP Sarah Haverstick, CPSTI

Teresa Plummer, PhD, OTR, ATP, CAPS Rachel Zoeller, PT, DPT, CPST

International Seating Symposium March 6, 2013

The Chair and Beyond: Choosing and Documenting

Equipment for Children

US CENSUS BUREAU: AMERICANS WITH DISABILITIES REPORT: 2010

Of the 62.2 million children under the age of 15, about 5.2 million or 8.4 percent had some kind of disability.

Half of children with a disability were classified with severe disabilities. 2.6 million children

US CENSUS BUREAU: AMERICANS WITH DISABILITIES REPORT: 2010

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US CENSUS BUREAU: AMERICANS WITH DISABILITIES REPORT: 2010 In children less than 3 years old, disability was defined as having either a developmental delay or having difficulty moving their arms or legs. About 2.3 percent of children under 3 years of age had one or both of these disabilities.

US CENSUS BUREAU: AMERICANS WITH DISABILITIES REPORT: 2010 For children aged 3 to 5, disability was defined as having a developmental delay or having difficulty walking, running, or playing. About 3.6 percent of children in this age group had one or both of these disabilities.

Among children aged 6 to 14, disability was defined on a wider range of activities and impairments. About 4.5 million children (12.2 percent) in this age group were classified as having a disability. roughly 5.3 percent of these children had a severe disability and 0.8 percent needed assistance with one or more ADLs.

US CENSUS BUREAU: AMERICANS WITH DISABILITIES REPORT: 2010

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In January 2011, the Rehabilitation Engineering and Assistive Technology Society of North America approved a Wheelchair Service Provision Guide to provide a framework for identifying the essential steps in the provision of a wheelchair using terminology from the International Classification of Functioning, Disability and Health (ICF) .

International Classification of Functioning, Disability and Health was developed in 2002 by the World Health Organization to provide a standard language and framework for the description of health and disability with the emphasis on health and functioning, rather than disease or disability

WHAT IS THE INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH (ICF) ?

•  ICF is a tool for measuring function in one’s environment

•  ICF is a universal approach that refrains from looking at individuals with a disability as a minority, realizing that disability can happen to anyone

•  ICF views health and function as an interactive process with one’s environment.

WHAT IS THE INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH (ICF) ?

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ICF Disability Model

Disability model is a basis for ICF which integrates medical and social factors

The disability model identifies levels of human function at the level of the body or body part, the whole person and the whole person in a social context.

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Health

conditions : disease, disorder,

injury

Environmental Factors:

social attitude, architectural

characteristics, social and legal

structures, climate, terrain, products and technology, support, and relationships

Personal Factors:

gender, age, coping style,

social background, education, experience, behavior, character

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Body Functions:

Physiologic functions of the body systems

such as cognitive, sensory, pain,

speech, cardiovascular, hematological,

respiratory, digestive, metabolic, endocrine,

neuromuscular, skin

Body Structures:

Anatomical parts of the

body such as eyes, ears,

nervous system, skin

Problems in body function and structures circulatory issues respiratory issues decreased cognitive level ROM limitations weakness or paralysis loss of sensation pain skin breakdown poor vision

WHAT IS IMPAIRMENT IN BODY FUNCTION OR STRUCTURE?

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Activity:

Execution or capacity to

execute a task or function such as learning and

applying knowledge, self care, mobility

and communication

Difficulty in executing activities Limited mobility Limited communication Decreased ability to perform self care/ADL’s

WHAT IS ACTIVITY RESTRICTION?

Participation:

A person’s involvement in a life situation

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Difficulty in involvement in a life situation, inability to participate with peers in recreation, school or community activities, lack of social relationships

WHAT IS PARTICIPATION RESTRICTION?

What is the child’s level of functioning? What treatment or intervention can maximize functioning? What is the child or family’s goal? What environment does the child need to function in? What support does the child have?

HOW DOES ICF APPLY IN THE ASSESSMENT OF A CHILD AND EQUIPMENT PLANNING ?

Need to know how different levels of disability link to different levels of health care Team management is critical for optimum outcomes

WHEN IMPAIRMENT AND ACTIVITY/PARTICIPATION RESTRICTIONS EXIST

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Intervention and Prevention = proper medical care health promotion education nutrition medication

WHEN THE LEVEL OF DISABILITY IS A HEALTH CONDITION

Intervention: medical care/medication/surgery oral medications botox injections phenol blocks surgical options ( ITB, SDR, tendon lengthenings, spinal fusion) Prevention: Rehabilitation to prevent development of activity limitations

WHEN THE LEVEL OF DISABILITY PRESENTS AS IMPAIRMENT

Intervention: assistive technology (wheelchairs, orthotics, walkers and gait trainers, adaptive chairs, standing frames, bath equipment, lifts, car seats) Personal assistance Rehabilitation Prevention: Preventative rehabilitation to avoid development of participation restriction

WHEN THE LEVEL OF DISABILITY IS AN ACTIVITY LIMITATION

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Intervention: Accommodations Public Education Anti-discrimination laws Universal design Prevention: Environmental Changes Accessible Services Universal Design Encouraging change in Societal Views

WHEN THE LEVEL OF DISABILITY IS PARTICIPATION RESTRICTION

Child Passenger Safety: Transporting Children with Special Healthcare Needs

Sarah Haverstick, CPSTI Rachel Zoeller, PT, DPT, CPST

International Seating Symposium

March 2013

Objectives •  To discuss the rates of motor vehicle crashes and it’s effect on

children in the United States. •  To demonstrate the importance of the knowledge and use of

medical child restraints for persons with special needs. •  To provide an overview of specialized child restraint systems

that are used in the transportation of persons with special health care needs.

•  To review the evaluation process for specialized transportation equipment.

•  To provide participants with information on the special needs transportation clinic located at the Monroe Carell Jr. Children’s Hospital at Vanderbilt.

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WHY TRANSPORTATION?

Rehab Therapist Knowledge •  Blake, E.; et al. 2006.

–  Online survey of rehab therapists –  18% response rate (1075 of 6000 invitations)

•  Physical Therapists: 70% •  Occupational Therapists: 18%

–  Reported knowledge/behavior •  53%: little or no knowledge •  79%: no formal training •  54%: no experience •  61%: little or no counseling with families on the subject

–  Authors recommend continuing education for rehab therapists regarding safe transportation

Source: Am J Phys Med Rehabil. 2006 Feb;85(2):181-4.

Motor vehicle crashes are the leading cause of injury death for children and young adults

in the United States.

Source: Centers for Disease Control, WISQARS, 2010 data

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Motor Vehicle/ Traffic

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BACKGROUND: CHILD PASSENGER SAFETY

Child Passenger Safety Technician •  National certification program developed by the National Highway Traffic Safety Administration (NHTSA) •  Certification program began in 1997 •  32 hour training •  Continuing education requirement for biannual recertification •  cert.safekids.org What do CPSTs do? •  Help with proper installation and use of child restraints and seat belts •  Access appropriate resources, provide families with current information, develop partnerships and solve problems •  Participate in community car seat checks •  Provide educational presentations •  Provide in-hospital consultations or fitting station appointments

What is a CPST?

Why do we need CPSTs? •  Most car seats are not installed properly! •  Five most common mistakes:

–  Wrong harness slot –  Chest clip out of position or not used –  Loose installation –  Loose harness –  Seat belt placement wrong

Source: NHTSA/Safe Kids Survey, September 2012

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CPS Laws & Recommendations

•  All states have a child passenger safety law – but each law varies in the ages it covers.

•  New recommendations released by AAP and NHTSA (March 2011):

•  Always rear-facing.

Birth – 12 months

•  Rear-facing as long as possible. •  Move to forward-facing once the rear-facing seat is outgrown.

1 – 3 years

•  Forward-facing in a five-point harness as long as possible. •  Move to belt positioning booster seat once harness is outgrown.

4 – 7 years

•  Belt positioning booster seat until 4’ 9” tall and fits properly in vehicle seat belt.

8 – 12 years

TN Child Restraint Law •  Special Needs Transportation: 55-9-602 (a)(4)(A)

–  If a child is not capable of being safely transported in a conventional child passenger restraint system as provided for in this subsection (a), a specially modified, professionally manufactured restraint system meeting the intent of this subsection (a) shall be in use; provided, however, that the provisions of this subdivision (a)(4) shall not be satisfied by use of the vehicle’s standard lap or shoulder safety belts independent of any other child passenger restraint system. A motor vehicle operator who is transporting a child in a specially modified, professionally manufactured child passenger restraint system shall possess a copy of the physician’s signed prescription that authorizes the professional manufacture of the specially modified child restraint system.

Infant Only •  Lower weight limits vary, typically 5 pounds; newer seats 4 pounds or birth •  Upper weight limits vary, typically 20 – 30 pounds •  Height limits typically between 29 – 35”

Convertible •  Rear-facing

•  Lower weight limit typically 5 pounds •  Upper weight limits vary, typically 20 – 40 pounds •  Upper height limits vary, typically 36 – 40”

•  Forward-facing •  Upper weight limits vary, typically 40 – 65 pounds •  Height limits vary, typically 34 – 43”

Forward facing with Harness (Convertible, Combination) •  Lower weight limit typically 20 pounds •  Upper weight limits vary, typically 40 – 80 pounds •  Upper height limits vary, typically up to 40” with harness (54” as belt positioning booster) •  Combination seats allow user to remove the harness and use as belt positioning booster seats (with high back)

Belt Positioning Booster •  Lower weight limit typically 30 pounds •  Upper weight limits vary, typically 80 – 100 pounds •  Upper height limits vary, typically 50 – 56” •  Must use lap and shoulder belt (cannot use lap belt only)

Conventional Transportation

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In most situations a conventional restraint will work for most children – even those with special healthcare needs

Restraint Selection •  Child’s Weight/Height

•  Important that the child not exceed the recommended weight or height limit of a child restraint.

•  Child’s Age •  Some medical seats come with specific age requirements, as well as height/weight. •  Always read the manufacturers instructions.

•  Vehicle •  What type of vehicle? Is LATCH available? Is there a tether anchor? •  Who else is typically transported with the child?

•  Medical Condition •  May influence the way the child needs to be restrained (Ex: a cast may not allow the child to sit upright in a conventional child restraint).

•  Medical Equipment •  Any equipment that must travel with the child may be a potential projectile in a crash. •  Equipment should be secured by seat belts or wedged on the vehicle floor with additional padding.

Conventional Restraints

Special Needs Transportation •  Additional training for CPSTs

–  Created by the Automotive Safety Program at Riley Hospital for Children, with funding from the National Safety Council.

–  Designed to expand the knowledge base of CPSTs in situations involving transporting children with medical conditions and procedures.

–  16 hour training, available to CPSTs. –  41 instructors across the country. –  www.preventinjury.org

RESEARCH BASE: SPECIAL NEEDS TRANSPORTATION

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Risk of Injury/Restraint Use •  Durbin, D.; et al. 2005.

–  Review of crash data to determine effect of seating position and appropriate restraint use on risk of injury to children in MVC.

–  Unrestrained children in front were at the highest risk of injury. –  Appropriately restrained children in the rear were at the lowest

risk of injury. –  Inappropriately restrained children were at nearly twice the risk

of injury. –  Age-appropriate restraints and rear-seating positions work

synergistically to provide the best protection in a crash.

Source: Pediatrics. 2005 Mar;115(3):e305-9.

Restraint Use Among Families

•  O’Neil, J.; et al. 2009. –  Comparison study of recommendations and practice. –  275 drivers transporting 294 children with special health care

needs were observed. –  82% of drivers had chosen the appropriate type of restraint. –  Only 27% of restraints were being used properly. –  24% of the seats observed were inappropriately modified. –  19% of the children could have used additional positioning

support during transportation. –  Only 8% of medical equipment was properly secured.

Source: Pediatrics. Vol. 124, No. 2. August 2009, p. 596-603.

Concerns of Families •  Falkmer, T.; Gregersen, N. 2002.

–  Questionnaire for caregiver’s of children with special healthcare needs.

–  Findings: •  Transfers in/out of vehicle are perceived as “risky.” •  Concerns identified due to poor postural sitting positions. •  Concerns identified due to lack of information/education.

Source: Falkmer T, Gregersen NP. Accid Anal Prev. 2002 .

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OVERVIEW OF SPECIALIZED RESTRAINT SYSTEMS

Car Beds •  Who?

–  Premature or low birth weight infants. –  Infants that fail car seat test prior to discharge. –  Other Dx: osteogenesis imperfecta, apnea, Pierre Robin sequence,

myelomeningocele, omphalocele, hydrocephalus, casts, etc.

•  What do they provide? –  Positioning options: supine, prone, side-lying.

•  Other considerations? –  Position relative to air bag in vehicle. –  Position relative to other passengers in vehicle.

Car Beds

Hope Car Bed (Merritt) Wt: 4.5 – 35

lbs Ht: up to 29 in

Dream Ride (Cosco)

Wt: 5 – 20 lbs Ht: 19 – 26 in

Angel Ride (Angel Guard) Wt: up to 9 lbs

Ht: up to 21.5 in

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Large Medical Seats •  Who?

–  Children that need additional support provided by a five-point harness (poor neck/trunk control, outgrown conventional restraint).

–  Children with temporary orthopaedic conditions (casts). –  Other Dx: behavioral considerations, neuromuscular disorders,

scoliosis, developmental delays, etc.

•  What do they provide? –  Five-point harness to higher weight limits (typically 100+ lbs). –  Additional lateral/trunk supports.

•  Other considerations? –  Large size of car seat (fit in vehicle, length of seat belt, etc.). –  Growth of child. –  Transfer of child into car seat when in vehicle. –  Availability of tether anchor.

Merritt Manufacturing •  Weight Limit

•  35 – 115 lbs • Height Limit

•  33.5 – 62 in • Key Features

•  Low sides •  Scoliosis Kit •  EZ Tether •  Stay Put Headrest

•  Other Considerations •  Narrow width (across shoulders)

Roosevelt

Columbia Medical •  Weight Limit

•  Small (2000): 20 – 102 lbs •  Large (2500): 20 – 130 lbs

• Height Limit •  Small: up to 60 in •  Large: 54 – 66 in

• Key Features •  Relatively lightweight (11 lbs) •  Wide body

•  Other Considerations •  High sides – difficult to lift heavier child into seat •  Top tether required

Columbia

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Spirit Columbia Medical • Weight Limit

–  25 – 130 lbs • Height Limit

–  Up to 66 in • Key Features

–  Positioning support – lateral supports, pommel –  Individual side harness adjustment –  Low sides for easy transfer

• Other Considerations –  Tether or long-belt path required

Britax/Snug Seat •  Weight Limit

•  22 – 105 lbs • Height Limit

•  33.5 – 62 in • Key Features

•  Recline bar (semi recline forward-facing)

• Other Considerations •  Top tether required

Traveler Plus

Britax/Snug Seat •  Weight Limit

•  Rear-facing: 5 – 33 lbs •  Forward-facing: 22 – 65 lbs

• Height Limit •  Up to 49 in

• Key Features •  Designed for children in spica or long-leg casts •  Optional pillow to adjust child’s fit in seat •  Option to semi-recline forward-facing

•  Other Considerations •  Harness length may be too short for older/larger casted children

Hippo

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Merritt Manufacturing •  Weight Limit

•  5 – 35 lbs • Key Features

•  Designed for omphalocele •  Support cushion for smaller children •  Rebound control bar •  Optional tether •  E-Z Leveling feature

•  Other Considerations •  Rear facing only

NEW – Hope Rear Facing

Other Medical Restraints

Special Tomato Carrie Recaro Peppino

Medical Boosters •  Who?

–  Children that have some neck/trunk control, but need more support than what is provided by the vehicle seat belt alone.

–  Other Dx: developmental delays, achondroplasia, neuromuscular disorders

•  What do they provide? –  More support than a seat belt, less than a five-point harness. –  Age appropriate option.

•  Other considerations? –  Availability of tether anchor. –  Behavior/maturity level of child.

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Churchill Merritt Manufacturing • Weight Limit

–  65 – 175 lbs • Height Limit

–  48 – 72 in • Key Features

–  Positioning support – hip inflexion wedge, pommel –  Stay put headrest –  Age appropriate for older children –  Compact and lightweight

• Other Considerations –  Requires LATCH or anchor installation

Pilot Sunshine Kids • Weight Limit

–  40 – 120 lbs • Height Limit

–  38 – 63 in • Key Features

–  Positioning support with vest and head rest –  Age appropriate for older children

• Other Considerations –  Narrow sides

NEW – Carrot 3 Convaid • Weight Limit

–  30 – 80 lbs • Height Limit

–  37 – 60 in • Ages

–  3 – 15 years • Key Features

–  “Free angle” recline – reclines at any position –  Available seat extension –  Optional pommel –  Tray & Footrest also available

• Other Considerations –  LATCH use is required –  Seatbelt use is required

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Vests •  Who?

–  Children that have some neck/trunk control, but need more support than what is provided by the vehicle seat belt alone.

–  Children with behavior considerations that have mastered unbuckling the seat belt or child restraint.

–  Other Dx: developmental delays, casts, etc.

•  What do they provide? –  Zipper options. –  Ability to install without a seat belt. –  Age appropriate option.

•  Other considerations? –  Availability of tether anchor. –  Behavior/maturity level of child.

E-Z On Upright Vest •  E-Z On Products

–  Weight Limit •  20 – 168 lbs (multiple size options)

–  Key Features •  Light, easy to transport •  Zipper in back (behavioral considerations) •  LATCH compatible

–  Other Considerations •  Tether/floor mount required

E-Z On Modified Vest •  E-Z On Products

–  Weight Limit •  Small: 20 – 65 lbs •  Large: 20 – 100 lbs

–  Key Features •  Allow child to lay supine on vehicle seat •  Designed for children in spica or long-leg casts •  Light, easy to transport

–  Other Considerations •  Availability of bench seat in vehicle •  Other vehicle passengers •  Comfort level of family

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Ride Safer Travel Vest •  Safe Traffic System, Inc.

–  Weight Limit •  Small: 35 – 60 lbs •  Large: 50 – 80 lbs

–  Height Limit •  Small: 38-52 in •  Large: 45 – 57 in

–  Key Features •  Compact and lightweight •  Provides trunk control to higher weight

–  Other Considerations •  Availability of tether anchor •  Comfort level of family

Medical Equipment Options •  NEW •  Available – Fall 2012 from Merritt

Manufacturing – Monitor Carrier – Medical Equipment Carrier

Medical Equipment Storage

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EVALUATION & CLINIC SERVICES

Rehab Therapist Evaluation •  Goal: Provide safe transportation options through family

centered care to improve quality of life. •  Evaluation:

–  Subjective History (social, medical, family concerns, etc.) –  Objective Assessment (pain, behavior, posture, strength, ROM

and functional mobility) –  Recommendations and Trials –  Vehicle Assessment –  Ordering Equipment –  Fitting and Caregiver Education (once equipment arrives)

Special Needs Transportation Clinic at Vanderbilt

•  Focus on education –  Two appointments (evaluation & fitting).

•  Who we serve –  Any child with medical diagnosis and transportation concerns –

with physician referral. –  Typically children are over the age of 3 and over 35 pounds. –  Common diagnoses: cerebral palsy, spina bifida, Downs

syndrome, autism, hydrocephalus.

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Special Needs Transportation Clinic at Vanderbilt

•  Clinic available every other week. •  Highly specialized staff (PT/OT and CPST

professionals). •  Requires physician referral. •  Seats are billed to insurance.

–  Large medical seats typically covered by most insurance plans. –  Seats that are denied or unable to be covered (conventional) are

charged to a grant received for this program.

When conventional restraints are no longer an

appropriate fit for the child

•  Typically, child is over 40 pounds or weight has exceeded the limit of their 5 point harness and they still require the upper body support provided by a 5 point harness •  Significant spinal deformities for children over 35 pounds that require custom positioning in car seat •  Behavioral safety concerns that are not met by conventional restraints

When to Refer?

Physician Referral •  Script for “Special Needs Medical Car Seat” •  Fax to: 343-0506 •  Pediatric Rehab will call family for appointment

Questions and Contact Information •  For questions regarding clinic and appointments

•  Pediatric Rehabilitation One Hundred Oaks at (615) 343-6445

•  For general child passenger safety questions and resources •  Safety Store at (615) 936-SAFE (7233) or (615) 936-1869

• www.childrenshospital.vanderbilt.org/carseats

How to Refer?

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Orthopaedic Loaner Program •  Partnership with Pediatric Rehabilitation. •  Available for children discharging in casts or

other devices that will not allow for the use of conventional child restraints. –  Ex: Hip or arm spica, Halo

•  Wiz Order for PT Evaluation placed while patient is in surgery.

•  Priority order for Rehabilitation Team.

Alternative Therapeutic Positioning

Principles of Therapeutic Positioning

•  Provide support: Support should be distributed over a broad area with no body part left unsupported.

•  Position for symmetry and alignment: –  Symmetry of head and trunk –  Nose, navel, knees and toes should be in forward alignment. –  Legs parallel

•  Offer variety •  Consider safety and comfort

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Why use therapeutic positioning?

•  To prevent deformities by minimizing influence of pathological forces on body posture and skeletal alignment

•  To set the stage for performance and function (e.g. provision of a stable base of support), thus promoting greater independence

•  To maintain health by improving physiological functioning of the body

•  To improve access for social, vocational and recreational activities •  To promote learning through the provision of a range of sensory

experiences •  To increase physical comfort and reduce fatigue

Considerations for Positioning •  Joint mobility •  Joint stability •  Neuromuscular and orthopedic limitations/

conditions •  Respiratory status •  Skin integrity •  Sensory function •  Sensory stimulation needs •  Social, cognitive and affective factors

Positioning Program •  24 hour approach to postural management (e.g. time in

wheelchair, alternative daytime positioning and while resting/sleeping in bed)

•  Designed by a team of professionals along with client and/or caregiver (s)

•  Incorporated into client and caregiver (s) established routines and schedule

•  Caregiver (s) must understand the rationale behind the program

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Why Position During Sleep?

•  To improve the quality and duration of sleep

•  To promote health and maintain safety during sleep

•  To prevent or lessen the development of orthopedic deformities

Alternative Therapeutic Positions •  Supine •  Prone •  Prone on forearms •  Quadruped on forearms •  Sidelying •  Sitting •  Standing

Benefits of Supine Positioning •  Promotes resting and sleeping •  Stretches kyphotic spine and rounded shoulders

posture by allowing gravity to limit spinal flexion and relax tight shoulder protractor musculature

•  Allows for facilitation of visual skill development for those individuals with limited head control

•  Decreases some types of edema when proper equipment is utilized

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Potential Problems With Supine Positioning

•  May encourage leg deformities (windswept, frogleg); also a difficult position to attain for those with LE contractures

•  May lead to pneumonia •  May lead to aspiration pneumonia as secretions pool in the back of

mouth and get sucked into the lungs •  May lead to breathing difficulties and snoring as oral structures (jaw,

tongue, etc) fall back •  May result in greater incidence of kidney stones, kidney infections or

kidney failure as it is difficult for kidneys to drain in this position •  Can facilitate abnormal reflexes, as well as GE reflux and vomiting •  May lead to potential skin breakdown for prolonged static posturing

over bony prominences •  Generally doesn’t promote interaction with the environment

Other Disadvantages to Supine

•  Most difficult position to lift arms against gravity

•  Often elicits the ATNR •  Encourages shallow breathing

Activities for Supine

•  Resting and relaxation •  Listening to music •  Watching TV •  Working or playing with activities hanging

from overhead •  UE strengthening

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Benefits of Prone Positioning

•  Promotes resting and sleeping •  Helps stretch mild tightness of the hips

and knees and may also help to stretch out kyphosis and rounded shoulders

•  Helps to develop head and upper trunk control

•  Facilitates kidney drainage

Contraindications for Positioning in Prone

•  Those with moderate to severe hip flexion tightness •  Those who cannot independently turn head •  Those with tracheostomies •  Those with Nasogastric (N/G) or Gastric (G) tubes that

cannot be accommodated •  Those with compromised respiratory capacity •  Those with hydrocephalus

Supports for Prone Positioning •  Lateral supports may be necessary to maintain

symmetrical body alignment •  Support over the hips may inhibit hip flexion and/or

provide a stable base for an individual with athetosis •  Supportive pillow under one hip can improve posture and

comfort for individual with a dislocated hip or pelvic obliquity

•  Roll placed under the ankle keeps pressure off the toes and prevents rotation of the legs

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Activities for Prone

•  Resting/sleeping •  Listening to music •  Watching TV •  Turning head from side to side and lifting

head up

Benefits of Prone on Forearms •  Improves head, trunk and upper body strength and shoulder stability •  Facilitates bilateral UE weight bearing through the shoulders, thus

enhancing hand development and function •  Helps to improve flexibility and stretch mild tightness at the

shoulders, elbows, hips and knees; gravity may help decrease scapular retraction

•  Encourages body extension •  Increases UE control •  Brings jaw forward for better lip closure and oral movements •  Aids in kidney drainage •  Can reduce gastroesophogeal reflux

Activities for Prone on Forearms •  Reaching and UE coordination activities •  Weight shifting from one arm to the other •  Raising and turning head •  Practicing rolling •  Drinking from a straw or feeding can be

addressed in this position •  Leisure activities such as watching TV or

listening to music

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Contraindications for Prone on Forearms Position

•  Moderate to severe shoulder flexion or hip tightness •  Poor head control •  Presence of an N/G or G-tube or tracheostomy may be a

contraindication •  Compromised respiratory status •  UE or LE Fractures •  Osteomalacia •  Arthritis or joint pain •  Hydrocephalus

Inverted Prone

•  Head is positioned lower than hips on a wedge

•  Promotes postural drainage •  Used only for brief periods (less than 5

minutes) •  Contraindicated with hydrocephalus as

intracranial pressure is increased

Benefits of Quadruped on Forearms

•  Improves head, neck and trunk control and strength, as well as hip and shoulder stability

•  Facilitates UE weight bearing through the shoulders •  Helps improve flexibility at the shoulders, elbows, hips

and knees and stretch tightness in the shoulders and spine

•  Increases upper trunk development and UE control for reaching and grasping

•  Brings jaw forward for better lip closure and oral motor movements

•  Aids in kidney drainage

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Contraindications for Quadruped on Forearms

•  Those with moderate to severe shoulder flexion or hip extension tightness may need greater modifications for this position

•  Those with mobility skills should be closely monitored to prevent falls from equipment

•  UE or LE Fractures •  Osteomalacia •  Arthritis or joint pain

Activities for Quadruped on Forearms

•  Reaching and UE coordination activities •  Weight shifting from one arm to the other •  Raising and turning head •  Eating/drinking or oral motor skill

acquisition activities •  Leisure activities such as watching TV,

listening to music

Benefits of Sidelying •  Promotes relaxation of body •  Decreases primitive reflex patterns •  Facilitates midline head position and may help person

with head movements •  Brings shoulders and arms forward and eliminates

gravity’s influence for easier use of one’s hands in midline

•  Helps to decrease windswept or frogleg deformities •  Gravity improves trunk elongation for an individual with

scoliosis, thus promoting improved respiration •  Promotes trunk, hip and knee flexion while reducing

extensor thrusting •  Elevated sidelying to the right decreases GE reflux and

facilitates gastric emptying making it a good position for feeding

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Potential Problems with Sidelying

•  Can cause shoulder pain in individuals with low tone

•  Can lead to deformities without proper support

Proper Support in Sidelying

•  Requires two pillows or head supports: one to keep the head in line with the shoulder and the other to keep the head slightly flexed

•  Uses various positioning blocks to achieve trunk and LE control

Activities in Sidelying •  Eye hand coordination activities at midline

(reaching, grasping, switch activation) •  Bilateral hand activities •  Eating/drinking or oral motor skill

acquisition in elevated sidelying •  Leisure activities including watching TV

and listening to the radio •  Interaction/communication

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Benefits of Sitting

•  Increases head and trunk control •  Provides free movement of arms and hands for eye hand

coordination activities •  Provides expansive view of the environment which improves visual

awareness •  Promotes good position for social interaction, working, feeding and

leisure activities •  Promotes good position for gastric emptying, kidney drainage and

breathing •  Facilitates mobility •  Enhances the development of perception and cognition through

visual and kinesthetic experiences

Potential Problems with Sitting •  Overuse of position increases the development of hip and

knee flexion contractures •  Skin breakdown may occur in those with compromised

circulation and lack of independent weight shifting •  Development of abnormal postures may occur as those

with minimal trunk control may compensate by using abnormal patterns

•  Significant modifications may be needed for those with severe deformities

Activities in Sitting •  ADLs •  Vocational activities •  Mobility •  Interaction/Communication •  Recreation and leisure activities •  Transportation

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Standing Types of standing aids: 1) prone standers

2) supine standers 3) vertical standers

4) dynamic standers 5) sit-to-stand standers

Prone Standers •  Allow for graduation of weight bearing while encouraging

a flexor bias •  Promotes development of head control, however child

needs to have some head control in order to use •  Strengthening of the upper thoracic spine, scapular

stabilizers and cervical extensors can occur by changing the forward tilt of the device

•  Difficult to position the child since child must be placed into stander in an upright position

Supine Standers •  Least stressful of the various standers

because some of the weight is supported through the back and not just the legs

•  Appropriate for use with a child who has limited head control

•  Often used with those children that are medically fragile (e.g. tracheostomies, G-tubes)

•  May help elicit the tonic labyrinthine reflex to increase extensor tone and alignment

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Vertical Standers •  Provides three point stabilization in a fully upright or

vertical position with supports at the knees, hips and lower torso

•  Provides less support than a prone or supine stander and are suited to those who have fairly good balance and trunk control

•  Good for those with postural insecurity or those who are developing lateral weight shifting skills

•  Types include: standing frame, standing box, standing table

Dynamic Standers •  Allow for mobility when in a standing position •  Good for those who spend a great deal of time standing

or who need maximum access to their environment •  Can be self propelled or motorized •  May be contraindicated for those with poor depth

perception, impaired upper extremity function, severe multisystem compromise and/or impaired safety awareness

Sit-to-Stand Standers •  Allows child to go from a sitting position to a

standing position •  May utilize a hydraulic or electric lift to assist •  Strapping often needs readjustment once

individual has moved into the standing position

•  Appropriate for individuals who are alert and interactive and having fair to good head control

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Benefits of Standing •  Provides greater access to social, vocational and recreational

activities as child views environment from an upright orientation

•  Improves the body’s physiological functioning (circulation, respiration, renal function, bowel function, bone density, etc.)

•  Reduces spasticity •  Increases ROM •  Prevents contractures in the LE •  Improves head and trunk control •  Increases arousal and alertness •  Increases overall endurance

Contraindications to Standing •  Severe medical conditions –

cardiopulmonary restrictions; skeletal compromise; neurological impingements and/or pain

•  Pain or spasticity, the use of a stander may need to be modified or discontinued

•  Severe LE or spinal contractures, standing may not be feasible

Gait Trainers

•  Allow supported dynamic standing •  Many different brands and many different

configurations

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Walkers

•  Rolling walkers – 2 wheels in front, child pushes – Problem: anterior trunk lean (hips in flexion,

line of gravity is anterior to feet) •  Posterior walkers

– More energy efficient, child is more upright – 2 or 4 wheels

Activities for Standing

•  ADLs •  Vocational activities •  Mobility •  Interaction/Communication •  Recreation and leisure activities

References:

Arledge, S., Armstrong, W., Babinec, M., Dicianno, B., Digiovine, C., Dyson-Hudson, T., Pederson, J., Piriano, J., Plummer, T., Rosen, L., Schmeler, M., Shea, M., Stogner, J. (2011). RESNA wheelchair service provision guide. Approved by RESNA Board of Directors. Awaad, Y., Tayem, H., Munoz, S., Ham, S., Michon, A.M., Awaad, R. (2003). Functional assessment following intrathecal baclofen therapy in children with spastic cerebral palsy. J Child Neurol; 18 (1): 26-34. Blake, E., Sherman, K., Morris, L. and Lapidus, G. Self-reported experience with safe transport of children with special healthcare needs: A rehabilitation therapist perspective 1006 3. American Journal of Physical Medicine and Rehabilitation, February(85), 181-184.

Bemis-Dougherty, A., Harwood, K. (2010). American Physical Therapy Association Learning Center. The international classification of functioning, disability and health: overview. http:/ / learningcenter.apta.org. Brault, M. (2012). Americans With Disabilities: 2010 Household Economic Studies Current Population Reports. http:/ /www.census.gov/prod/2012pubs/p70-131.pdf

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Chad, K.E., Bailey, D.A., McKay, H.A., Zello, G.A., Snyder, R.E . (1999). The effect of a weight-bearing physical activity program on bone mineral content and estimated volumetric density in children with spastic cerebral palsy. J Pediatr; 135 (1): 115-117. Durbin, D., Chen, I., Smith, R., Elliott, M., & Winston, F. (2005). Effects of seating position and appropriate restraint use on the risk of injury to children in motor vehicle crashes. Pediatrics, (115), 305-309. Eisenberg, S., Zuk, L., Carmeli, E., Katz-Leurer, M. (2009). Contribution of stepping while standing to function and secondary conditions among children with cerebral palsy. Pediatric Physical Therapy; 21 (1): 79-85.

Falkmer, T., & Gregersen, N. (2002). Perceived risk among parents concerning the travel situation for children with disabilities. Accident; Analysis and Prevention, July(34), 553-562.

Fenton, B.A. (2007, July). Standing tall. Rehab Management. Fragala, M.A., Goodgold, S., Dumas, H.M. (2003). Effects of lower extremity passive stretching: Pilot study of children and youth with severe limitations in self mobility. Pediatri Phys Ther; 15: 167-175. Fraser, B.A, Hensinger, R.N., & Phelps, J.A. (1990).Physical management of multiple handicaps: A professional’s guide (2nded.). Baltimore: Paul H. Brooks Publishing. Gerber, D.L., McAllister, S., & Tencza, C.B. Challenges in physical management. Therapeutic Concepts, Inc. Glickman, L., Geigle, P., Paleg, G. (2010). A systematic review of supported standing programs. Journal of Pediatric Rehab Medicine; 3: 197-213. Gudjonsdottir, B., Stemmons Mercer, V. (2002). Effects of a dynamic versus a static prone stander on bone mineral density and behavior in four children with severe cerebral palsy. Pediatric Physical Therapy;14 (1): 38-46.

Kecskemethy, H.H., Herman, D., May, R., Paul, K., Bachrach, S.J., Henderson, R.C. (2008). Quantifying weight bearing while in passive standers and a comparison of standers. Dev Med Child Neurol ; 50 (7): 520-523. Lange, M.L. (2009, February 2). Sleep positioning: Positioning isn’t just for wheelchairs anymore. Advance for Occupational Therapy Practitioners, 34-35.

Low, S., McCoy, S.W., Beling, J., Adams, J. (2011). Pediatric physical therapists’ use of support walkers for children with disabilities: A nationwide survey. Pediatr Phys Ther; 23: 381-389.

Mattern-Baxter, K. (2009). Effects of partial body weight supported treadmill training on children with cerebral palsy. Pediatr Phys Ther; 21: 12-22. O’Neil, M., Fragala-Pinkham, M.A., Westcott, S.L., Martin, K., Chiarello, L.A., Vlavano, J., Rose, R.U. (2006). Physical Therapy clinical management recommendations for children with cerebral palsy- spastic diplegia: Achieving Functional Mobility Outcomes. Pediatri Phys Ther; 18: 49-72.

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O'Neil, J., Yonkman, J., Talty, J., & Bull, M. (2009). Transporting children with special health care needs: Comparing recommendations and practice. Pediatrics, August(124), 596-603.

Pin, T.W. (2007). Effectiveness of static weight-bearing exercises in children with cerebral palsy. Pediatri Phys Ther; 19 (2); 172-8. Rigby, P., Ryan, S., & Campbell, K. (2009). Effect of adaptive seating devices on the activity performance of children with cerebral palsy. Archives of Physical Medicine and Rehabilitation, 90, 1389-95.

Ryan, S. (2012). An overview of systematic reviews of adaptive seating interventions for children with cerebral palsy: Where do we go from here? Disability and Rehabilitation: Assistive Technology, 7(2), 104-111.

Ryan, S.E., Campbell, K.A., Rigby, P.J., Fishbein-Germon, B., Hubley, D., Chan, B. (2009). The impact of adaptive seating devices on the lives of young children with cerebral palsy and their families. Arch Phys Med Rehabil; 90 (1): 27-33.

Stuberg, W.A. (1992). Considerations related to weight-bearing programs in children with developmental disabilities. Phys Ther; 72: 35-40.

Tremblay, F., Malouin, F., Richards, C.L., Dumas, F. (1990). Effects of prolonged muscle stretch on reflex and voluntary muscle activations in children with spastic cerebral palsy. Scand J Rehabil Med; 22 (4): 171-180. World Health Organization. (2002). Towards a common language of functioning, disability and health. Geneva. http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf

Thank you!